Download a. Human Immunodeficiency Virus (HIV) Infections

1.
Chapter 1: Certain Infectious and Parasitic Diseases (A00B99)
a.
Human Immunodeficiency Virus (HIV) Infections
1)
Code only confirmed cases
Code only confirmed cases of HIV infection/illness. This is an
exception to the hospital inpatient guideline Section II, H.
In this context, “confirmation” does not require documentation
of positive serology or culture for HIV; the provider’s
diagnostic statement that the patient is HIV positive, or has an
HIV-related illness is sufficient.
2)
Selection and sequencing of HIV codes
(a)
Patient admitted for HIV-related condition
If a patient is admitted for an HIV-related condition, the
principal diagnosis should be B20, Human
immunodeficiency virus [HIV] disease followed by
additional diagnosis codes for all reported HIV-related
conditions.
(b)
Patient with HIV disease admitted for unrelated
condition
If a patient with HIV disease is admitted for an
unrelated condition (such as a traumatic injury), the
code for the unrelated condition (e.g., the nature of
injury code) should be the principal diagnosis. Other
diagnoses would be B20 followed by additional
diagnosis codes for all reported HIV-related conditions.
(c)
Whether the patient is newly diagnosed
Whether the patient is newly diagnosed or has had
previous admissions/encounters for HIV conditions is
irrelevant to the sequencing decision.
(d)
Asymptomatic human immunodeficiency virus
Z21, Asymptomatic human immunodeficiency virus
[HIV] infection status, is to be applied when the patient
without any documentation of symptoms is listed as
being “HIV positive,” “known HIV,” “HIV test
positive,” or similar terminology. Do not use this code
if the term “AIDS” is used or if the patient is treated for
any HIV-related illness or is described as having any
condition(s) resulting from his/her HIV positive status;
use B20 in these cases.
(e)
Patients with inconclusive HIV serology
Patients with inconclusive HIV serology, but no
definitive diagnosis or manifestations of the illness,
may be assigned code R75, Inconclusive laboratory
evidence of human immunodeficiency virus [HIV].
(f)
Previously diagnosed HIV-related illness
Patients with any known prior diagnosis of an
HIV-related illness should be coded to B20. Once a
patient has developed an HIV-related illness, the patient
should always be assigned code B20 on every
subsequent admission/encounter. Patients previously
diagnosed with any HIV illness (B20) should never be
assigned to R75 or Z21, Asymptomatic human
immunodeficiency virus [HIV] infection status.
(g)
HIV Infection in Pregnancy, Childbirth and the
Puerperium
During pregnancy, childbirth or the puerperium, a
patient admitted (or presenting for a health care
encounter) because of an HIV-related illness should
receive a principal diagnosis code of O98.7-, Human
immunodeficiency [HIV] disease complicating
pregnancy, childbirth and the puerperium, followed by
B20 and the code(s) for the HIV-related illness(es).
Codes from Chapter 15 always take sequencing
priority.
Patients with asymptomatic HIV infection status
admitted (or presenting for a health care encounter)
during pregnancy, childbirth, or the puerperium should
receive codes of O98.7- and Z21.
(h)
Encounters for testing for HIV
If a patient is being seen to determine his/her HIV
status, use code Z11.4, Encounter for screening for
human immunodeficiency virus [HIV]. Use additional
codes for any associated high risk behavior.
If a patient with signs or symptoms is being seen for
HIV testing, code the signs and symptoms. An
additional counseling code Z71.7, Human
immunodeficiency virus [HIV] counseling, may be
used if counseling is provided during the encounter for
the test.
When a patient returns to be informed of his/her HIV
test results and the test result is negative, use code
Z71.7, Human immunodeficiency virus [HIV]
counseling.
If the results are positive, see previous guidelines and
assign codes as appropriate.
b.
Infectious agents as the cause of diseases classified to
other chapters
Certain infections are classified in chapters other than Chapter 1 and
no organism is identified as part of the infection code. In these
instances, it is necessary to use an additional code from Chapter 1 to
identify the organism. A code from category B95, Streptococcus,
Staphylococcus, and Enterococcus as the cause of diseases classified
to other chapters, B96, Other bacterial agents as the cause of diseases
classified to other chapters, or B97, Viral agents as the cause of
diseases classified to other chapters, is to be used as an additional code
to identify the organism. An instructional note will be found at the
infection code advising that an additional organism code is required.
c.
Infections resistant to antibiotics
Many bacterial infections are resistant to current antibiotics. It is
necessary to identify all infections documented as antibiotic resistant.
Assign a code from category Z16, Resistance to antimicrobial drugs,
following the infection code only if the infection code does not
identify drug resistance.
d.
Sepsis, Severe Sepsis, and Septic Shock
1)
Coding of Sepsis and Severe Sepsis
(a)
Sepsis
For a diagnosis of sepsis, assign the appropriate code
for the underlying systemic infection. If the type of
infection or causal organism is not further specified,
assign code A41.9, Sepsis, unspecified organism.
A code from subcategory R65.2, Severe sepsis, should
not be assigned unless severe sepsis or an associated
acute organ dysfunction is documented.
(i)
Negative or inconclusive blood cultures and
sepsis
Negative or inconclusive blood cultures do not
preclude a diagnosis of sepsis in patients with
clinical evidence of the condition, however, the
provider should be queried.
(ii)
Urosepsis
The term urosepsis is a nonspecific term. It is
not to be considered synonymous with sepsis. It
(iii)
(iv)
has no default code in the Alphabetic Index.
Should a provider use this term, he/she must be
queried for clarification.
Sepsis with organ dysfunction
If a patient has sepsis and associated acute organ
dysfunction or multiple organ dysfunction
(MOD), follow the instructions for coding
severe sepsis.
Acute organ dysfunction that is not clearly
associated with the sepsis
If a patient has sepsis and an acute organ
dysfunction, but the medical record
documentation indicates that the acute organ
dysfunction is related to a medical condition
other than the sepsis, do not assign a code from
subcategory R65.2, Severe sepsis. An acute
organ dysfunction must be associated with the
sepsis in order to assign the severe sepsis code.
If the documentation is not clear as to whether
an acute organ dysfunction is related to the
sepsis or another medical condition, query the
provider.
(b)
Severe sepsis
The coding of severe sepsis requires a minimum of 2
codes: first a code for the underlying systemic
infection, followed by a code from subcategory R65.2,
Severe sepsis. If the causal organism is not
documented, assign code A41.9, Sepsis, unspecified
organism, for the infection. Additional code(s) for the
associated acute organ dysfunction are also required.
Due to the complex nature of severe sepsis, some cases
may require querying the provider prior to assignment
of the codes.
2)
Septic shock
(a)
Septic shock generally refers to circulatory failure
associated with severe sepsis, and therefore, it
represents a type of acute organ dysfunction.
For cases of septic shock, the code for the systemic
infection should be sequenced first, followed by code
R65.21, Severe sepsis with septic shock or code
T81.12, Postprocedural septic shock. Any additional
codes for the other acute organ dysfunctions should also
be assigned. As noted in the sequencing instructions in
the Tabular List, the code for septic shock cannot be
assigned as a principal diagnosis.
3)
Sequencing of severe sepsis
If severe sepsis is present on admission, and meets the
definition of principal diagnosis, the underlying systemic
infection should be assigned as principal diagnosis followed by
the appropriate code from subcategory R65.2 as required by the
sequencing rules in the Tabular List. A code from subcategory
R65.2 can never be assigned as a principal diagnosis.
When severe sepsis develops during an encounter (it was not
present on admission) the underlying systemic infection and
the appropriate code from subcategory R65.2 should be
assigned as secondary diagnoses.
Severe sepsis may be present on admission but the diagnosis
may not be confirmed until sometime after admission. If the
documentation is not clear whether severe sepsis was present
on admission, the provider should be queried.
4)
Sepsis and severe sepsis with a localized infection
If the reason for admission is both sepsis or severe sepsis and a
localized infection, such as pneumonia or cellulitis, a code(s)
for the underlying systemic infection should be assigned first
and the code for the localized infection should be assigned as a
secondary diagnosis. If the patient has severe sepsis, a code
from subcategory R65.2 should also be assigned as a secondary
diagnosis. If the patient is admitted with a localized infection,
such as pneumonia, and sepsis/severe sepsis doesn’t develop
until after admission, the localized infection should be assigned
first, followed by the appropriate sepsis/severe sepsis codes.
5)
Sepsis due to a postprocedural infection
(a)
Documentation of causal relationship
As with all postprocedural complications, code assignment is
based on the provider’s documentation of the relationship
between the infection and the procedure.
(b)
Sepsis due to a postprocedural infection
For such cases, the postprocedural infection code, such as,
T80.2, Infections following infusion, transfusion, and
therapeutic injection, T81.4, Infection following a procedure,
T88.0, Infection following immunization, or O86.0, Infection
of obstetric surgical wound, should be coded first, followed by
the code for the specific infection. If the patient has severe
sepsis the appropriate code from subcategory R65.2 should
also be assigned with the additional code(s) for any acute organ
dysfunction.
(c)
Postprocedural infection and postprocedural septic
shock
In cases where a postprocedural infection has occurred and has
resulted in severe sepsis and postprocedural septic shock, the
code for the precipitating complication such as code T81.4,
Infection following a procedure, or O86.0, Infection of
obstetrical surgical wound should be coded first followed by
code R65.21, Severe sepsis with septic shock and a code for
the systemic infection.
6)
Sepsis and severe sepsis associated with a noninfectious
process (condition)
In some cases a noninfectious process (condition), such as
trauma, may lead to an infection which can result in sepsis or
severe sepsis. If sepsis or severe sepsis is documented as
associated with a noninfectious condition, such as a burn or
serious injury, and this condition meets the definition for
principal diagnosis, the code for the noninfectious condition
should be sequenced first, followed by the code for the
resulting infection. If severe sepsis, is present a code from
subcategory R65.2 should also be assigned with any associated
organ dysfunction(s) codes. It is not necessary to assign a code
from subcategory R65.1, Systemic inflammatory response
syndrome (SIRS) of non-infectious origin, for these cases.
If the infection meets the definition of principal diagnosis it
should be sequenced before the non-infectious condition.
When both the associated non-infectious condition and the
infection meet the definition of principal diagnosis either may
be assigned as principal diagnosis.
Only one code from category R65, Symptoms and signs
specifically associated with systemic inflammation and
infection, should be assigned. Therefore, when a non-infectious
condition leads to an infection resulting in severe sepsis, assign
the appropriate code from subcategory R65.2, Severe sepsis.
Do not additionally assign a code from subcategory R65.1,
Systemic inflammatory response syndrome (SIRS) of noninfectious origin.
See Section I.C.18. SIRS due to non-infectious process
7)
Sepsis and septic shock complicating abortion,
pregnancy, childbirth, and the puerperium
See Section I.C.15. Sepsis and septic shock complicating
abortion, pregnancy, childbirth and the puerperium
8)
Newborn sepsis
See Section I.C.16. f. Bacterial sepsis of Newborn
e.
Methicillin Resistant Staphylococcus aureus (MRSA)
Conditions
1)
Selection and sequencing of MRSA codes
(a)
Combination codes for MRSA infection
When a patient is diagnosed with an infection that is due to
methicillin resistant Staphylococcus aureus (MRSA), and that
infection has a combination code that includes the causal organism
(e.g., sepsis, pneumonia) assign the appropriate combination code
for the condition (e.g., code A41.02, Sepsis due to Methicillin
resistant Staphylococcus aureus or code J15.212, Pneumonia due
to Methicillin resistant Staphylococcus aureus). Do not assign
code B95.62, Methicillin
resistant Staphylococcus aureus infection as the cause of diseases
classified elsewhere, as an additional code because the combination
code includes the type of infection and the MRSA organism. Do not
assign a code from subcategory Z16.11, Resistance to penicillins,
as an additional diagnosis.
See Section C.1. for instructions on coding and sequencing of
sepsis and severe sepsis.
(b)
Other codes for MRSA infection
When there is documentation of a current infection (e.g., wound
infection, stitch abscess, urinary tract infection) due to MRSA, and
that infection does not have a combination code that includes the
causal organism, assign the appropriate code to identify the
condition along with code B95.62, Methicillin resistant
Staphylococcus aureus infection as the cause of diseases
classified elsewhere for the MRSA infection. Do not assign a code
from subcategory Z16.11, Resistance to penicillins.
(c)
Methicillin susceptible Staphylococcus aureus
(MSSA) and MRSA colonization
The condition or state of being colonized or carrying MSSA or
MRSA is called colonization or carriage, while an individual person
is described as being colonized or being a carrier. Colonization
means that MSSA or MSRA is present on or in the body without
necessarily causing illness. A positive MRSA colonization test
might be documented by the provider as “MRSA screen positive” or
“MRSA nasal swab positive”.
Assign code Z22.322, Carrier or suspected carrier of Methicillin
resistant Staphylococcus aureus, for patients documented as
having MRSA colonization. Assign code Z22.321, Carrier or
suspected carrier of Methicillin susceptible Staphylococcus
aureus, for patient documented as having MSSA colonization.
Colonization is not necessarily indicative of a disease process or
as the cause of a specific condition the patient may have unless
documented as such by the provider.
(d)
MRSA colonization and infection
If a patient is documented as having both MRSA colonization and
infection during a hospital admission, code Z22.322, Carrier or
suspected carrier of Methicillin resistant Staphylococcus aureus,
and a code for the MRSA infection may both be assigned.